Archive for the Private Category

Meet the Team


Dr. Puneeta Tandon, MD

Project Lead

(University of Alberta)


Michelle Carbonneau

Project Co-Lead 

(University of Alberta)


 Dr. Ashley Hyde, PhD

Postdoctoral Fellow

(University of Alberta)


 Dr. Mahmod Mohamed, MBBCh

GI Partner with expertise in Quality Improvement 

(University of Alberta)


Emily Johnson

Masters Student

(University of Alberta)


Dr. Kinjal Patel, MD

Internal Medicine Resident Advisor

(University of Alberta)


Derek Drager

Patient Lead

Development of the content hosted on this site is part of a large quality improvement project supported by Alberta Innovates called Cirrhosis Care Alberta (CCAB). Thank you to those listed below who contributed to the development and review of materials on this site or supported the Cirrhosis Care Alberta project.
Thank you also to the many team members not listed below who have contributed to the CCAB project outside of the content contained in this website. We are grateful for everyone’s ongoing contributions and support!


Dr. Juan Gonzalez-Abraldes, MD (University of Alberta)

Dr. Wayne Bai, MBChB (University of Alberta)

Dr. RJ Bailey, MD (University of Alberta)

Dr. Vincent Bain, MD (University of Alberta)

Dr. Jasmohan Bajaj, MD (Virginia Commonwealth University)

Dr. Annalisa Berzigotti, MD (University of Bern)

Dr. Rahima Bhanji, MD (University of Alberta)

Dr. Patricia Bloom, MD (University of Michigan)

Dr. Meredith Borman, MD (University of Calgary)

Dr. Kelly Burak, MD (University of Calgary)

Dr. Carla Coffin, MD (University of Calgary)

Dr. Stephen Congly, MD (University of Calgary)

Dr. Bertus Eksteen, MBChB (University of Calgary)

Dr. Guadalupe Garcia-Tsao, MD (Yale University)

Dr. Leah Gramlich, MD (University of Alberta)

Dr. Klaus Gutfreund, MD (University of Alberta)

Dr. Rajveer Hundal, MD (University of Calgary)

Dr. Patrick Kamath, MD (Mayo Clinic College of Medicine)

Dr. Constantine Karvellas, MD (University of Alberta)

Dr. Adriana Lazarescu, MD (University of Alberta)

Dr. Mang Ma, MD (University of Alberta)

Dr. Vladimir Marquez, MD (University of British Columbia)

Dr. Kaleb Marr, MBBS (University of Calgary)

Dr. Andy Mason, MBBS (University of Alberta)

Dr. Jessica Mellinger, MD (University of Michigan)

Dr. Mahmod Mohamed, MBBCh (University of Alberta)

Dr. Aldo Montano–Loza, MD (University of Alberta)

Dr. Arpan Patel, MD (West Los Angeles VA Medical Center)

Dr. Alnoor Ramji, MD (University of British Columbia)

Dr. David Ryan, MBBChBAO (Central Alberta Digestive Disease Specialists)

Dr. Matt Sadler, MD (University of Calgary)

Dr. Vijey Selvarajah, MD (University of Alberta)

Dr. Hemant Shah, MD (University of Toronto)

Dr. Laura Stinton, MD (University of Calgary)

Dr. Elliot Tapper, MD (University of Michigan)

Dr. Nneka Ufere, MD (Harvard Medical School)

Dr. Sander Veldhuyzen Van Zanten, MD (University of Alberta)

Dr. Shawn Wasilenko, MD (University of Alberta)

Dr. Malcolm Wells, MD (University of Alberta)

Dr. Winnie Wong, MD (University of Alberta)

Dr. Marilyn Zeman, MD (University of Alberta

Internal Medicine

Dr. Neeja Bakshi, DO (University of Alberta)

Dr. S. Monty Ghosh, MD (University of Calgary)

Dr. Narmin Kassam, MD (University of Alberta)

Dr. Kinjal Patel, MD (Internal Medicine Resident, University of Alberta)

Dr. Jeff Schaefer, MD (University of Calgary)

Dr. Winnie Sia, MD (University of Alberta)

Dr. Benjamin Sugars, MD (University of Alberta)

Dr. Yolande Westra, MD (University of Alberta)

Dr. Christopher Woodrell, MD (The Icahn School of Medicine at Mount Sinai)

Pain Management Specialist

Dr. Saifee Rashiq, BMBS (University of Alberta)

Intensive Care Medicine

Dr. Brian Buchanan, MD (University of Alberta)

Dr. Constantine Karvellas, MD (University of Alberta)

Radiation Oncology

Dr. Nawaid Usmani, MD (University of Alberta)


Dr. Pen Li, MD (University of Alberta)


Dr. Sara Davison, MD (University of Alberta)

Dr. Neesh Pannu, MD (University of Alberta)


Dr. Nicholas Mitchell, MD (University of Alberta)

Dr. Sarah Tymchuk, MD (University of Alberta)

Infectious Disease Specialists

Dr. Lynora Saxinger, MD (University of Alberta)

Dr. Uma Chandran, MD (University of Alberta)


Dr. Christopher Fung, MD (University of Alberta)

Dr. Philippe Sarlieve, MD (University of Alberta)

Palliative Care

Dr. Amanda Brisebois, MD (University of Alberta)

Dr. Sarah Burton-Macleod, MD (University of Alberta)

Dr. Ingrid DeKock, MBChB (University of Alberta)

Dr. Martin Labrie, MD (University of Calgary)

Dr. Noush Mirhosseini, MD (University of Alberta)

Dr. Mino Mitri, MD (University of British Columbia)

Dr. Arpan Patel, MD (University of California, Los Angeles)

Dr. Aynharan Sinnarajah, MD (University of Calgary)

Dr. Christopher Woodrell, MD (Mount Sinai Hospital)

Addiction Medicine Specialists

Dr. Kathryn Dong, MD (University of Alberta)

Dr. S. Monty Ghosh, MD (University of Calgary)

Family Medicine

Dr. Dalia Abdel Latif, MBChB (University of Alberta)

Dr. Amanda Brisebois, MD (University of Alberta)

Dr. Denise Campbell-Scherer, MD (University of Alberta)

Dr. Echo-Marie Enns, MD (University of Calgary)

Dr. Lee Green, MD (University of Alberta)

Dr. Mehrnoush Mirhosseini, MD (University of Alberta)

Dr. Jasneet Parmar, MBBS (University of Alberta)

Dr. Aynharan Sinnarajah, MD (University of Calgary)

Nurse Practitioners

Sandra Anderson (Alberta Health Services)

Lisa Douglas (Alberta Health Services)

Trudy Matwiy (Alberta Health Services)

Kimberly Newnham (Alberta Health Services)

Margaret Jackson (Alberta Health Services)

Michelle Stone (University of Alberta)

Registered Nurses

Shannon Beaudoin (Alberta Health Services)

Kristen Eisenkren (Alberta Health Services)

Ralph Ennis-Davis (Alberta Health Services)

Ally Jeannotte (Alberta Health Services)

Donna Perez-Aguierre (University of Alberta Hospital)

Hannah Rempel (University of Alberta Hospital)

Dr. Jude Spiers, PhD (University of Alberta)

Lisa Westin (Alberta Health Services)

Registered Dietitians

Marlis Atkins (Alberta Health Services)

Dawn Belland (Alberta Health Services)

Vanessa Den Heyer (Alberta Health Services)

Karolina Sekulic (Alberta Health Services)

Stephanie Krug (Alberta Health Services)

Amy Wedman (Alberta Health Services)


Omer Ghutmy (Alberta Health Services)

Dr. Meghan Mior, Pharm D (Covenant Health Canada)

Occupational Therapy

Kathleen Ng (Alberta Health Services)

Social Workers

Franklin Adamson (Alberta Health Services)

Sylvia Carbert (Alberta Health Services)

Dee Miner (Alberta Health Services)

Implementation Scientists

Dr. Denise Campbell-Scherer, MD (University of Alberta)

Dr. Leah Gramlich, MD (University of Alberta)

Dr. Michael Stickland, PhD (University of Alberta)

Dr. Dawn Schroeder, PhD (University of Alberta)


Kathleen Ismond (University of Alberta)

Shanuki Goonasekera (Summer Student 2020)

Ajaypaul Sidhu (Summer Student 2020)

Lynn Sukkarieh (Summer Student 2020)

Deepan Hazra (Summer Student 2021)

Education Advisors

Heather Ball (Alberta Health Services)

Jennifer Cowles (Alberta Health Services)

Yvette Debrecen (Alberta Health Services)

Lesly Deuchar (Alberta Health Services)

Shawnee Eidt (Alberta Health Services)

Nem Maksimovic (Canadian Liver Foundation)

Louise Morrin (Alberta Health Services)

Kellie Quian (Alberta Health Services)

Leanne Reeb (Alberta Health Services)

Karen Seto (Canadian Liver Foundation)

Patient Advisors

Pat Cox

Scott Bridges

Doug Buchholtz 

Marten De Vlieger

Leroy Schalk

Dennis Silbernagel

Bob Steeves

Barb & Craig Wallace

Chris Wenzel

Multimedia Team

David Cornish (Digital Marketing Consultant)

Ruturaj Gole (Website Development)

Erin Ottosen (Material Editor)

Jordan Tate (Web Illustrator)

Jennifer van Gennip (Video Development)

Pixel Designs team (Website Development)

Dr. Jan Kowalczewski, PhD (Medical Illustrator, Website Development, Video Development,)

Ascites (fluid in the abdomen) Test

When to Get Help

Contact your healthcare provider right away or go to the emergency department if you have:

  • trouble breathing
  • new or sharp pain in your belly that doesn’t go away
  • a fever
  • nausea and vomiting

What is Ascites?

The most common major complication of cirrhosis is ascites (pronounced “a-sigh-tees”). When pressure in the portal vein gets too high (called portal hypertension), fluid leaks out and builds up. This can make your abdomen enlarge like a balloon filled with water. Ascites might be diagnosed with a physical exam. You may need other tests like an ultrasound (to look for fluid) or paracentesis (to take a sample of the fluid for testing).

Ascites can be very uncomfortable. Eating can be a problem because you have less room for food. Even breathing can be a problem, especially when you’re lying down. It can also lead to fluid buildup in the space around your lungs (called pleural effusion or hepatic hydrothorax), or abdominal hernias – especially umbilical hernias (when tissue from inside the abdomen bulges out through a weak spot in the navel or belly button).

The most dangerous problem associated with ascites is an infection called spontaneous bacterial peritonitis (SBP), which can be life-threatening. Some symptoms of SBP are fever, abdominal pain, nausea and vomiting, or confusion. If you get spontaneous bacterial peritonitis (SBP), you will need antibiotics to treat it. After you recover, you will probably be prescribed another antibiotic to prevent getting SBP again.


Treatment for ascites caused by cirrhosis can include more than one of the options listed below.

Low Sodium (Salt) Diet

Restricting sodium is an important part of ascites treatment. Too much sodium can make your body hold on to extra fluid. This fluid can pool in your belly, chest and legs. Eating foods with less sodium can help control ascites.

  • Aim to eat less than 2000 mg of sodium a day.
  • One teaspoon of salt has about 2300 mg of sodium.
  • All types of salt contain the same amount of sodium, including table salt, sea salt, and Himalayan salt.

Tips to reduce sodium:

  • At first, foods may taste bland. Over time, your taste buds get used to less salt.
  • Don’t add salt to your food while cooking or at the table.
  • Choose fresh, unprocessed, and homemade foods.
  • Eat less processed, packaged, or restaurant foods.
  • Limit condiments and sauces (ketchup, mustard, soy sauce, gravies, salad dressings).
  • Limit pickled foods, olives, chutneys, and dips.
  • To boost flavours, try adding spices, seasoning mixes with no salt added, lemon, lime, vinegar, fresh or dry herbs, garlic, or onions

Read food labels


Diuretic Medicine

Diuretic medicines such as furosemide and spironolactone can also help to get rid of the fluid that has built up in the abdomen (belly) and other parts of the body. If you have ascites, your doctor may prescribe a diuretic for you to take.

If you are taking diuretics, it is important to weigh yourself daily to monitor the effect of diuretics. One litre of ascites weighs about 2.2 pounds (1 kg). Gradual weight loss is a sign of decreasing ascites – this is expected and desired when diuretics are first started. Losing weight too quickly can be dangerous.

You should also have your blood work checked as recommended by your healthcare team because diuretics can effect your kidneys and electrolyte levels. Your dose of diuretics can be adjusted by your healthcare team if you are losing weight too quickly, having side effects, or they don’t seem to be working.

Let your healthcare team know if you are experiencing:

  • dizziness
  • a decrease in urination
  • confusion or sleepiness
  • have ongoing or worsening swelling in your abdomen (belly)
  • are losing weight too quickly: 2 pounds (0.9 kg) or more in a day, for 2 days in a row, OR more than 7 pounds (3.2 kg) in a week


Paracentesis is a procedure used to remove ascites fluid.

Sometimes paracentesis is used to take a sample of the fluid for determining why it’s building up. Paracentesis might also be used if you have cirrhosis and the following circumstances:

  • You have severe ascites. It’s causing extreme discomfort, abdominal pain, and difficulty breathing. A paracentesis treatment may relieve the discomfort before you begin treatment with one or more diuretics.
  • You haven’t responded to the standard ascites treatment of a low-salt diet and diuretic medicines, or your body is unable to tolerate diuretic medications. This is the case in less than 10% of people with ascites. In this situation, you may require paracentesis repeatedly.
  • Your doctor suspects the fluid is infected.

Other Treatments

Your healthcare team may recommend other treatment options. Options available to you will depend on lots of different factors like your age, other medical conditions and how sick your liver is. Some other treatment options might include:

Self Care Tips:

  • weigh yourself each morning before breakfast, before you drink anything or take medicine, and after you pee (urinate).
  • Keep track of your weight in a notebook or app on your phone. Most people will see changes in weight readings, even before they notice changes in how their abdomen looks or feels.
  • If you are taking diuretics (water pills), have your blood tests done regularly to check your kidneys and electrolytes as recommended by your health team.

Let your healthcare provider know if you:

  • feel dizzy
  • are not passing enough urine
  • are losing weight too quickly: 2 pounds (0.9 kg) or more in a day, for 2 days in a row, OR more than 7 pounds (3.2 kg) in a week
  • have ongoing or worsening swelling in your abdomen (belly)
  • gain 2 pounds (0.9 kg) or more in a day, for 2 days in a row, OR gain 5 pounds (2.3 kg) in a week


The information on this page was adapted (with permission) from the references below, by the Cirrhosis Care Alberta project team (physicians, nurse practitioners, registered nurses, registered dietitians, physiotherapists, pharmacists, and patient advisors).

This information is not intended to replace advice from your healthcare team. They know your medical situation best. Always follow your healthcare team’s advice.


  1. US Department of Veterans Affairs, Veterans Health Administration 
  2. Canadian Liver Foundation
Last reviewed March 15, 2021

Indwelling peritoneal catheters (IPCs) for Refractory Ascites

In patients with refractory ascites, therapeutic options may be limited. Patients often require frequent paracentesis.  

Although Indwelling peritoneal catheters (IPCs) are typically used in malignant ascites, they can be considered in patients with refractory ascites related to cirrhosis (requiring paracentesis at least monthly despite diuretics). 

In a 2019 systematic review, Macken et al. concluded “Despite lack of well-designed studies, preliminary data suggests low significant complication rates; however safety and efficacy of permanent indwelling peritoneal catheters in end-stage liver disease remains to be confirmed”.

A randomized controlled trial by the same authors (PMID 32478917) published in 2020 compared large-volume paracentesis vs long-term abdominal drains in refractory ascites patients who were not candidates for liver transplantation. All participants were given ciprofloxacin 500 mg po daily as antibiotic prophylaxis. No protocolized albumin was given in the long-term abdominal drain arm. Costs and time in hospital were lower in the indwelling drain group and there was no difference in the incidence of peritonitis (6% in the indwelling drain group and 11% in the large- volume paracentesis group.

Placement is generally ordered after consultation with a liver specialist, weighing the risks vs benefits.

Step 1:

Evaluate patient candidacy for other first line therapies for refractory ascites management:

  • TIPS
  • Liver transplant

Step 2: 

Consider potential contraindications to IPC placement:

Candidate for liver transplant
Theoretical risk of causing a cocoon abdomen or sclerosing encapsulating peritonitis
Fluid septationsDrain will likely not be effective to manage ascites. Can rule out with ultrasound
Thin abdominal wallCan make tunnelling the drain challenging.
Pre-insertion consult by an interventional radiologist should be considered in these circumstances
Severe abdominal anasarca Drain insertion site will be less likely to heal, resulting in higher risk for long term leaking from the site
Pre-insertion consult by an interventional radiologist should be considered in these circumstances
Cognitive impairmentPatients may have challenges with the self-management activities required to care for the drain and may be at higher risk for damage or dislodgement of the drainage tube
Immunosuppressed (i.e. prior organ transplant, immunosuppression, etc.)May increase the chance of infection
Unsafe living environmentWill limit the ability for home care to provide support in the community

Step 3: 

Provide pre-procedure patient counselling:

  • Theoretical increased risk of SBP, although in small studies that include prophylactic antibiotics, risk does not appear greater than standard SBP
  • Long-term prophylactic antibiotics will be prescribed 
  • Leakage is the most common complication
  • Submersing the drain (bathing or swimming) is not recommended
  • IV albumin may still be recommended at times depending on drainage volume and renal function 
  • Homecare services are required for maintenance of the drain
  • Drainage frequency can be adjusted, and some patients may need daily drainages

Step 4:

Arranging IPC placement and follow up care:

  1. Send referral to interventional radiology for “Abdominal PleurX insertion”.
  2. Once booking date known, send referral and drain management orders to Community Care Access. Be sure to include: 
    1. Home Care Referral Form
    2. Patient demographic sheet
    3. Medication list
    4. Home Care Management Orders
  3. Provide patient with prescription for SBP prophylaxis to be started 1 day prior to drain insertion (Norfloxacin 400mg daily, Ciprofloxacin 500mg daily, or Septra DS one tab daily).
  4. Send Drain Placement Orders to diagnostic imaging recovery area one day prior to insertion date. 
  5. Arrange routine lab work for the patient (lab or home collections). Frequency should be based on patient goals of care and risk of complications.

Management Recommendations:

Drain Site Leaking
  • Occurs most commonly in the early weeks after the drain is inserted. To manage leaking, until the drain site heals, consider more aggressive ascites drainage +/- albumin replacement (to preserve renal function). 
  • We recommend against removing the drain site suture until the drain site has healed and leaking stopped. 
  • Putting a suture to tighten the exit site of the IPC site should be done as well.  If ineffective, another option is using medical grade glue applied at the leaking exit site.  
  • Avoid bagging or placing a fluid collection system around the drain as this may promote infection and shift focus away from healing the drain site. 
  • Dressings should be changed frequently during periods of leaking so that wet dressings are not sitting against the skin for prolonged periods of time.
Renal dysfunction & albumin replacement
  • If renal function is declining it is good practice to: 

            a) evaluate whether diuretics can be reduced and

            b) consider reducing total drain volumes or change to more frequent small volume drains

  • The decision to give albumin should be based on the patient’s renal function, hemodynamic status, weekly drain volumes and ability to tolerate drain volumes. In general, we recommend albumin 1g/kg in situations such as:

           a) stage 1 acute kidney injury

           b) symptomatic hypotension, and 

           c) when drain volume >10L/wk.

  • Many patients will require no or minimal albumin, however we recommend patients be monitored for progressive serum albumin depletion and resultant renal dysfunction.
  • Albumin does not usually need to be given within a specific time frame following drainage procedures and should instead be arranged in an ambulatory setting where clinically appropriate.
Spontaneous Bacterial Peritonitis (SBP)
  • We recommend routine monitoring for SBP. Home care staff can collect fluid for cell count and differential. Fluid collection for culture and sensitivity is not commonly available in the community. 
  • If the polymorphonuclear (PMN) count is >250mm/cm3, fluid should be collected for culture and treatment for SBP initiated. 
  • If the fluid culture is positive with normal cell count (bacteriascites), and the patient is asymptomatic, case-by-case evaluation is required. At a minimum, clinical status, labs, and fluid analysis (cell count and culture) should be repeated within 2-3 days of the initial fluid culture.
  • It is not well understood whether an IPC should be remove or left in situ if the patient develops a single episode of SBP. If this situation occurs, case-by-case evaluation is required considering the patient’s goals of care, whether the patient is experiencing recurring infections, and the type of bacteria cultured (common SBP bacteria vs not).
Pain during vacuum drainage

Patients can experience significant pain at the end of the drain procedure when vacuum bottles are used. Most can learn to recognize when they are about to experience pain and clamp the drain prior, however some may require modification (switch to gravity drainage system or adjust the clamp to slow the drainage rate).

Skin Cellulitis
  • A cellulitis is suggested by the presence of warm, erythematous, and painful skin.  If a cellulitis is suspected, a trial of antibiotics for 1 week can be considered.  This often is enough to resolve the infection.  
  • We recommend sending fluid for cell count and differential, and also for bacterial culture to rule out a SBP which would warrant specific antibiotics, and potentially drain removal.
Skin Irritation

When patients experience skin irritation or a rash around the drain insertion site, modifications to skin cleansing and dressing materials should be considered. Home care can typically make modifications as they see fit.

Drain tunnel fistula/hernia (fluid filled)

Recommend more aggressive ascites drainage +/- albumin replacement as tolerated, to reduce risk of rupture.

Blood tinged ascites

Episodic blood tinged ascites has been reported and typically resolves spontaneously. Evaluate fluid for infection and assess hemodynamic status.

Downloadable content:

You can download these to print or view offline:

Community Care Access

Home Care Referral Form

Home Care Management Orders

Drain Placement Orders